Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
If you have a patient with isolated CN VII palsy (Bell's Palsy), and straightforward symptoms with no red flags (such as concern for carcinomatous meningitis), do you routinely get an MRI brain or do you just make a clinical diagnosis?
In my practice, I do not order a brain MRI if there are no red flags. I treat with a course of steroids; 60 mg of prednisone for four days, 40 mg for four days, 20 mg for four days and then stop. I see the patient back in six weeks. If they have not made a complete recovery, I perform MRI imaging wi...
Do you recommend taking any unique approaches to managing patients with persistent hypertension following bilateral renal artery stenting?
Yes, I will be more aggressive with lipid management, sometimes using PCSK9-INH in addition to a statin, if the cause of the renal artery stenosis was atherosclerotic-related. Also, I typically get yearly ultrasounds to evaluate the patency of the renal artery stents. From a management perspective, ...
Do you discontinue or adjust azathioprine when a patient develops elevated MCV after starting it?
Great question, with practical implications for the clinic: Azathioprine (AZA) is a prodrug that likely exerts its immunosuppressive effects against B- and T-cell function by interfering with purine metabolism through its metabolites (including 6-MP). Logically, many of the "classic" AZA side effect...
What is your approach to counseling a patient with stable but severe multivessel coronary disease if the patient does not wish to undergo bypass surgery?
The question assumes that a stable patient with multivessel disease would do better with bypass surgery. If the ejection fraction is less than 35% then the long-term outcome from the STITCH trial showed a reduction in mortality. There is no comparable data for angioplasty. If the patient refuses sur...
What is a reasonable way to treat statin-induced myalgia and what statin substitute would you consider using in the event the myalgia is not resolved?
Qunol co administration Vytorin - lower doses PCSK9
What are your next steps when managing patients with suspected Gitelman syndrome for whom genetic testing reveals variants of uncertain significance or novel mutations not well characterized?
If the patient had a clinical syndrome that fit the Gitelman phenotype I would totally treating as such.
How do you approach methotrexate management around vaccines other than COVID and influenza?
The COVID pandemic has highlighted impaired vaccine responses in our patient populations and current data was nicely summarized in Friedman et al., PMID: 34493491.Evidence had preceded the pandemic regarding diminished response to pneumococcal vaccination in patients with RA on methotrexate. My appr...
How do you approach the treatment of drug-induced thrombotic microangiopathy?
Typically, transplant-related TMA is due to sirolimus, tacrolimus, cyclosporine, or some combination of those drugs. The first step is to reduce the dose. Often keeping the drug at the lower end of the therapeutic level, the TMA will resolve or ameliorate. If, for instance, sirol and tac are used to...
How do you advise patients with paroxysmal atrial fibrillation regarding their caffeine consumption, given that a randomized clinical trial found no association between caffeine intake and the triggering of AF episodes?
There is no data to support that limited caffeine consumption should not be forced upon patients for AF prevention because it does not cause AF. Then again, there are patients who are sensitive to it and they should avoid it. I think patients are told to stop it because we want to blame something fo...
Following abaloparatide use for osteoporosis treatment, how long do you consolidate with bisphosphonates before considering a drug holiday?
6 months